A powerful bomb exploded outside Delhi High Court gate number 5 on Wednesday morning. The blast took place at around 10.15 am. It left 11 people dead and more than 100 injured. This is the second such incident at the High Court this year.

Half of all early casualties seek medical care over first hour. To know the total number of casualties, double this number after one hour. This formula is often used by the media to predict the tolls. It is also useful to predict demand for care and resource needs.

The most severely injured arrive after the less injured who self–transport to the closest hospitals, so always expect upside down triage.

It is important that we as doctors know how bomb blast cause injuries in order to tackle the repercussions of bomb blasts. Bomb blast injuries can be categorized into four types:

Primary blast injuries are a direct result of the impact of the over pressurized blast wave on the body. It involves injuries to the hollow gas–filled organs like the lungs, ear drum or intestines leading to their rupture.

Secondary blast injuries occur due to flying debris and bomb fragments causing penetration or penetrating injuries to organs such as eyes.

Tertiary blast injuries occur when individuals are thrown by the blast wind leading to fractures due to the fall.

Quaternary blast injuries are due to direct effect of burn or crush injuries.

The most important aspect is not to waste energies and resources on patients with non–serious injuries.

Look for eardrum rupture and signs of respiratory imbalance. Their absence indicates a non–serious injury.

If the ear drums are intact, the patient can be discharged with first–aid treatment.

If ear drum is ruptured, immediately do an X–ray chest. Keep the patient under observation for eight hours as primary blast injuries may have a delayed presentation.

Hence, otoscopic ear exam can be used as a screening procedure for triage. Decreased oxygen saturation on pulse oximetry signals early blast lung injury, even before symptoms become apparent.

CHENNAI: Even as the Indian Council of Medical Research is getting set to launch a country–wide study to arrive at Indian diagnostic reference values, here are the results of a study involving over 8,000 participants that underline the urgency of such a task. The results of the first phase of Sri Ramachandra University’s PURSE–HIS project, conducted between April 2008 and June 2011, clearly demonstrates the fact that a different set of reference or ‘normal’ values will have to be narrowed down for the Indian ethnic group. There is undoubtedly a need for a different set of reference values for the Indian population, S. Thanikachalam, who led the project at SRU, said. "For instance, one–third of the population has conditions conducive to the development of a vascular illness – stroke, heart attack, peripheral vascular disease, among others." In fact, the study showed that the normal reference value for vascular aging among Indians was much higher than in the Caucasian population. Carmel Mary McEniery, senior researcher, University of Cambridge, said the aging was advanced by at least 10 years, in comparison with the Caucasian population. Thereby, the vascular age of a 30–year–old in India would be comparable only to that of a 40–year–old in, say, the United Kingdom.
(Source: http://www.thehindu.com/news/states/tamil–nadu/article2427481.ece, September 6, 2011)

JAIPUR: The health ministers of member states of the WHO South–East Asia Region (SEAR), participating at the 29th Health Ministers’ Meeting (HMM) in Jaipur on Tuesday unanimously acknowledged anti–microbial resistance as a major global public health issue. They adopted a ‘Jaipur Declaration’ to combat anti–microbial resistance. "We recognize that it is imperative that national governments accord utmost priority to this hitherto neglected problem to preserve efficacy of the anti–microbial agents – in our fight against microbial diseases," he said. The health ministers of 11 member countries, including India, Bangladesh, Bhutan, DPR Korea, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor–Leste agreed to 18 points, which are mentioned in the ‘Jaipur Declaration’ to fight against anti–microbial resistance. The ministers have recognized that anti–microbial resistance can be an impediment in global efforts towards achieving UN Millennium Development Goals (MDG), especially MDG 6 that addresses containment of HIV/AIDS, tuberculosis, malaria and other diseases. Now they have agreed to institute a coherent, comprehensive and integrated national approach to combat antimicrobial resistance. Also, they have advocated developing national antibiotic policy and formulating multi–sectoral national alliances against anti–microbial resistance. (Source: TOI, Sep 7, 2011)

Adenoidectomy doesn’t decrease the number of colds and sinus infections in young children, according to results of a randomized controlled study. When frequent upper respiratory tract infection was the only cause for surgery in kids ages 1 to 6, adenoid removal wasn’t any better than watchful waiting in reducing the rate of these infections, Anne G.M. Schilder, MD, PhD, of University Medical Centre Utrecht, the Netherlands and colleagues found. (Source: Medpage Today)

Smoking prevalence in the U.S. has fallen over the last five years, but not at a consistent rate, CDC researchers said. The percentage of adults who smoke fell from 20.9% in 2005 to 19.3% in 2010 (P<0.05 for trend), a 1.6% drop that amounts to about three million fewer smokers than there would have been with no decline, Brian King, PhD, of the CDC, and colleagues reported in the Sept. 6 Morbidity & Mortality Weekly Report. (Source: Medpage Today)

Infections with Babesia protozoan parasites –– normally a tickborne disease –– from blood transfusions have escalated recently, suggesting that the blood supply is increasingly at risk for contamination, CDC researchers said. A total of 159 transfusion–related babesiosis cases from 1979 to 2009 have been confirmed, with more than three–quarters occurring in the last decade, Barbara L. Herwaldt, MD, MPH, at CDC headquarters in Atlanta, and colleagues reported online in Annals of Internal Medicine. (Source: Medpage Today)

What is the impact of exercise on those with pulmonary arterial hypertension?

Maintaining healthy heart function is not as easy as going for a jog each day for those suffering with pulmonary arterial hypertension (PAH). To slow damage to their heart, patients need to do all that they can, and exercise can potentially improve their quality of life. However, many patients have a higher chance of suffering the consequences of overexertion due to the demands of pumping blood into stiffened, large arteries and narrow small arteries, making it hard to decide on how much exercise a patient should do.

Researchers from the University of Wisconsin–Madison aim to clear up this uncertainty by attempting to quantify the exact impact of exercise on individuals with PAH. Associate professor of biomedical engineering Naomi Chesler and team have been awarded a four year grant of $2.5 million by the National Institutes of Health. This will allow them to research the relationships between small artery narrowing, large artery stiffening and their interactions with the right side of the heart in those with PAH.

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinews)

Can a young person with heart attack have normal coronary arteries?

#DrKKAnswers: Prevalence of significant coronary blockages is lower in younger women presenting with chest pain than in men. In 3% of young patients with heart attack, the coronaries may be normal. Most of them have blockages less than 40% or mild irregularities in the coronary arteries leading to acute heart attack because of plaque rupture and thrombus formation.

Every one cannot be a spiritual seeker. In fact majority are not interested in seeking spiritual knowledge and they keep themselves busy in the worldly desires. To become a good seeker one needs to acquire many qualities.

The dictionary describes depression as a condition of general emotional dejection and withdrawal, sadness greater and more prolonged than that warranted by any objective reason. The question here is why does one get depressed? Is it the inability to cope with the situation or the high stress levels that come with success or failure? Life is full of twists and turns, some pleasant others not so pleasant or at times dreadful. No one is devoid of problems in their lives. Everyone has their own personal set of problems. Even the people who have a smile constantly on their face have problems. The only difference is they know how to tackle the problems of their life and smile about the fact that they can overcome those problems, similar to Mother Nature.

Someone compared the changes in Mother Nature with depression so aptly. He said each year nature sheds all its charm and the vibrant colors but then again it blooms to its optimum capacity to smile and teach us the most valuable lesson of life. Seasonal changes are the main reason for depression in nature. Change is inevitable, be it in nature or in our life, but what are the changes is subjective. They may differ person to person, and so will the approach towards them.

Getting into depression is a normal phenomenon, but letting it over take us completely is not the best thing. There are no specific rules or concepts to deal with it, whatever way one feels is the best way, and one should adopt to tackle it.

Here are some really easy ways to tackle this "blown out of proportion problem".

Lead your life on the basis of fundamental values of what is right and what’s wrong.

Avoid hurting others and yourself too.

It’s easier to change and adapt ourselves to new circumstances, than to expect vice a versa.

There are many liver diseases which cause symptoms similar to those of biliary atresia. Consequently, many tests may have to be performed before biliary atresia can be diagnosed conclusively.

Serum bilirubin: Conjugated hyperbilirubinemia, defined as any level exceeding either 2 mg/dL or 20% of total bilirubin, is always abnormal. Interestingly, infants with biliary atresia typically show only moderate elevations in total bilirubin, which is commonly 6–12 mg/dL, with the direct (conjugated) fraction comprising 50–60% of total serum bilirubin.

GGTP levels may be within the reference range in some forms of cholestasis of hepatocellular origin.

Aminotransferase levels are not particularly helpful in establishing a diagnosis, although a markedly elevated alanine aminotransferase level (>800 IU/L) indicates significant hepatocellular injury and is more consistent with the neonatal hepatitis syndrome.

Ultrasonography may demonstrate absence of the gallbladder and no dilatation of the biliary tree. Unfortunately, the sensitivity and specificity of these findings, even in the most experienced centers, probably do not exceed 80%.

Hepatobiliary imaging, using technetium–labeled di–isopropyl iminodiacetic acid (DISIDA) nuclear scintiscan, is useful in evaluating infants with suspected biliary atresia. Unequivocal evidence of intestinal excretion of radiolabel confirms patency of the extrahepatic biliary system. It is important to keep the following two in mind: First, reliability of the scintiscan is diminished at very high conjugated bilirubin levels (>20 mg/dL). Second, the test has been associated with a 10% rate of false–positive or false–negative diagnostic errors.

Percutaneous liver biopsy is widely regarded as the most valuable study for evaluating neonatal cholestasis. Morbidity is low in patients without coagulopathy. When examined by an experienced pathologist, an adequate biopsy specimen can differentiate between obstructive and hepatocellular causes of cholestasis, with 90% sensitivity and specificity for biliary atresia.

The most advanced technique gives a pregnancy rate of at best 50–60% per attempt. Definitely there is lot more to be understood. We are hosting a Conference on 8th – 9th of October at Le’ Meridian, New Delhi on Current Practices and Recent Advances in ART (CUPART 2011). We have invited a very respectable panel of International and National faculty whose experiences will be a wealth of knowledge to us.

Under the aegis on AOGD

Organizing Chairperson – Dr Kaberi Banerjee

Day 1: Interesting Highlights

Session 2 – An IVF Cycle – All that you needed to know

All basics and important steps of an IVF cycle will be covered in this session.

The ammonia test is primarily used to help investigate the cause of changes in behavior and consciousness. It may be ordered, along with other tests such as glucose, electrolytes, and kidney and liver function tests, to help diagnose the cause of a coma of unknown origin or to help support the diagnosis of Reye’s syndrome or hepatic encephalopathy caused by various liver diseases. An ammonia level may also be ordered to help detect and evaluate the severity of a urea cycle defect.

In some cases no trace of poison is found on analysis although from other circumstances it is quite certain that poison was the cause of illness or death. The possible explanations of a negative finding are:

The poison may have been eliminated due to vomiting, stomach wash or diarrhea

The whole of the poison may have disappeared from the lungs by evaporation or oxidation

The poison after absorption may have been detoxified, conjugated and eliminated from the system

Some drugs are rapidly metabolized, making extraction difficult.

Some biological toxins and venoms, which are protein in nature cannot be separated from body tissues.

Some organic poisons especially alkaloids may, by oxidation during life, or due to faulty preservation, or a long interval of time, or from decomposition of the body, deteriorate and cannot be detected.

If the poison act slowly and death is delayed following production of irreversible organic changes, the poison may be completely metabolized and excreted.

Many drugs may be present in very small amounts and these may require considerable amount of viscera for their identification.

Yesterday’s Mind Teaser: All of the following statements regarding vas deference are true except:

1. The terminal part is dilated to form ampulla.
2. It crosses ureter in the region of ischial spine.
3. It passes lateral to inferior epigastric artery at deep inguinal ring.
4. It is separated from the base of bladder by the peritoneum.

Answer for Yesterday’s Mind Teaser: 4. It is separated from the base of bladder by the peritoneum.

While my friend was working as a receptionist for an eye surgeon, a very angry woman stormed up to her desk. "Someone stole my wig while I was having surgery yesterday," she complained. The doctor came out and tried to calm her down. "I assure you that no one on my staff would have done such a thing," he said. "Why do you think it was taken here?"

"After the operation, I noticed the wig I was wearing was cheap–looking and ugly." "I think" explained the surgeon gently, "that means your cataract operation was a success."

How do bomb blast cause injuries? It is crucial that we know this to handle the aftermath of bomb blasts.

Primary blast injuries are the injuries to the hollow gas–filled organs like the lungs, ear drum or intestines leading to their rupture. These occur as a direct result of the impact of the over pressurized blast wave on the body.

Secondary blast injuries occur due to flying debris and bomb fragments leading to penetration or penetrating injuries such as to the eyes.

Tertiary blast injuries occur when individuals are thrown by the blast wind leading to fractures as a result of the fall.

Quaternary blast injuries are due to direct effect of burn or crush injuries.

The most important triage to manage blast injuries is not to waste energies and resources on patients with non-serious injuries, said Padma Shri and Dr B C Roy National Awardee Dr. K.K. Aggarwal, President Heart Care Foundation of India and MTNL Perfect Health Mela.

The most important thing is to check for eardrum rupture and signs of respiratory imbalance. Their absence indicates a non–serious injury. All patients exposed to a blast must have eardrum examination as the first step. If the ear drums are intact, the patient can be discharged with first–aid treatment. If ear drum is ruptured, an X–ray chest should be done immediately. All such patients should be observed for eight hours as primary blast injuries are notorious for delayed presentation.

Doctors should therefore focus only on two exams: Otoscopic ear exam and pulse oximetry. Blast lung injury is unlikely without tympanic or ear membrane rupture. Thus is used as a screening procedure for admitting a patient. Decreased oxygen saturation on pulse oximetry signals early blast lung injury, even before symptoms become apparent.

Half of all initial casualties seek medical care over first hour. Double this number after one hour and you will know the total casualties. This formula is often used by the media to predict the tolls. It is also useful to predict demand for care and resource needs.

Always expect upside down triage as the most severely injured arrive after the less injured who self–transport to the closest hospitals.

The Government should take all steps so that blasts do not occur. With the increasing use of explosives in terrorist events in our country in recent times, doctors, especially Emergency Doctors, should undergo training every six months so that they are prepared and better equipped to manage several casualties all at one time. There is a need for constant updation. Govt. should formulate guidelines, which should be available on their website and can be followed by all.